accident-causation

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AC1 ACCIDENT CAUSATION

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AC2 Early Man

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AC3 Factory managers reasoned that workers were hurt because — ACCIDENT PEOPLE PROBLEM Industrial Revolution Number is Up People Error Carelessness Act of God Cost of doing Business

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AC4 “Industrial Accident Prevention” 1932 First Scientific Approach to Accident/Prevention - H.W. Heinrich. Domino Theory MISTAKES OF PEOPLE

Heinrich’s Theorems : 

AC5 Heinrich’s Theorems INJURY - caused by accidents. ACCIDENTS - caused by an unsafe act –injured person or an unsafe condition – work place. UNSAFE ACTS/CONDITIONS - caused by careless persons or poorly designed or improperly maintained equipment. FAULT OF PERSONS - created by social environment or acquired by ancestry. SOCIAL ENVIRONMENT/ANCESTRY - where and how a person was raised and educated.

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AC6 Heinrich’s Theory Corrective Action Sequence (The three “E”s) Engineering Education Enforcement

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AC7 Modern Causation Model OPERATINGERROR RESULT: No damage or injury Many fatalities Major damage MISHAP (POSSIBLE)

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AC8 How accidents are caused & how to correct those causes. Parallels Heinrich's to a point. Injury is called RESULT, indicating it could involve damage as well as personal injury and the result can range from no damage to the very severe. The word MISHAP is used rather than Accident to avoid the popular misunderstanding that an accident necessarily involves injury or damage. Finally, the term OPERATING ERROR is used instead of Unsafe Act & Unsafe condition. Modern Causation

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AC9 Operating Errors: Being in an unsafe position Stacking supplies in unstable stacks Poor housekeeping Removing a guard Examples

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AC10 Revolutionized accident prevention A weakness in the design or operation of a system or program Systems Defect

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AC11 Examples Systems defects include: Improper assignment of responsibility Improper climate of motivation Inadequate training and education Inadequate equipment and supplies Improper procedures for the selection & assignment of personnel Improper allocation of funds

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AC12 Modern Causation Model OPERATINGERRORS RESULT: No damage or injury Many fatalities Major damage MISHAP (POSSIBLE) SYSTEM DEFECTS Operating Errors occur because people make mistakes, but more importantly, they occur because of SYSTEM DEFECTS

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AC13 System defects occur because of Managers design the Systems Modern Causation Model OPERATINGERRORS RESULT: No damage or injury Many fatalities Major damage MISHAP (POSSIBLE) SYSTEM DEFECTS COMMAND ERROR MANAGEMENT / COMMAND ERROR

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AC14 A defect in some aspect of the safety program that allows an avoidable error to exist. Ineffective Information Collection Weak Causation Analysis Poor Countermeasures Inadequate Implementation Procedures Inadequate Control Safety Program Defect

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AC15 SAFETY MANAGEMENT ERROR A weakness in the knowledge or motivation of the safety manager that permits a preventable defect in the safety program to exist. Safety Management Error

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AC16 Modern Causation Model SAFETY MANAGEMENT ERROR SAFETY PROGRAM DEFECT COMMAND ERROR SYSTEM DEFECT OPERATING ERROR MISHAP RESULTS

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AC17 Initial studies show for each disabling injury, there were 29 minor injuries and 300 close calls/no injury. Recent studies indicate for each serious result there are 59 minor and 600 near-misses. INITIAL STUDIES RECENT STUDIES Near-Miss Relationship

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AC18 There are seven avenues through which we can initiate countermeasures. None of these areas overlap. They are: Safety management error Safety program defect Management / Command error System defect Operating error Mishap Result Seven Avenues

Seven Avenues : 

AC19 Seven Avenues Potential countermeasures for each modern causation approach include:

Seven Avenues : 

AC20 Seven Avenues Potential countermeasures for each modern causation approach include: REVISE INFORMATION COLLECTION ANALYSIS IMPLEMENTATION 2

Seven Avenues : 

AC21 Seven Avenues Potential countermeasures for each modern causation approach include: COMMAND ERROR 3

Seven Avenues : 

AC22 Seven Avenues Potential countermeasures for each modern causation approach include: SYSTEM DEFECT 4

Seven Avenues : 

AC23 Seven Avenues Potential countermeasures for each modern causation approach include:

Seven Avenues : 

AC24 Seven Avenues Potential countermeasures for each modern causation approach include:

Seven Avenues : 

AC25 Seven Avenues Potential countermeasures for each modern causation approach include: 7

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AC26 A system is simply a group of interrelated parts which, when working together as they were designed to do, accomplish a goal. Using this analogy, an installation or organization can be viewed as a system. The elements of the Army Systems Model are: Task Person Training Environment Materiel Army Systems Model

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AC27 TASK Army Systems Model Communication Control Arrangement Demands on soldiers Time aspects

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AC28 PERSON Army Systems Model Selection Mentally Physically Emotionally Qualified Motivation Positive Negative Retention

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AC29 Army Systems Model TRAINING Types Initial Update Remedial Targets Operator Supervisor Management Considerations Quality/Quantity

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AC30 Army Systems Model ENVIRONMENT Noise Weather Facilities Lighting Ventilation

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AC31 Army Systems Model MATERIEL Supplies Equipment Machine Design Maintenance

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Army Systems Model SYSTEM DEFECT Army Systems Model Task Training Environment Materiel Person

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AC33 ARE THERE ANY QUESTIONS?

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AC34